Social distancing to minimize transmission of coronavirus disease 2019 (COVID-19) is virtually impossible in correctional facilities, whose residents live in close confinement, share toilets and showers, and typically sit shoulder-to-shoulder in mess halls.

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The Centers for Disease Control and Prevention (CDC) notes that people who are incarcerated or detained in a particular facility often come from a variety of locations, increasing the chance of introducing COVID-19. Plus, options to isolate people with COVID-19 are usually limited, and many facilities restrict access to soap and paper towels and ban alcohol-based hand sanitizers.

In addition, incarcerated individuals are more likely than the general population to have underlying illnesses, such as cancer, diabetes, or substance use disorder, that increase their risk of developing severe COVID-19, said Daniel Lopez Acuña, MD, MPH, who helped craft new COVID-19 guidelines for prisons and jails for the World Health Organization (WHO).

As he and his coauthors noted in a March 17 article, people in prison often experience earlier onset and greater severity of such conditions than the general population. What’s more, older age alone puts many incarcerated people, who are serving decades-long sentences, at an increased risk of severe COVID-19.

“It’s not such a different situation than what you have in nursing homes for old people,” said Lopez Acuña, an adjunct professor at the Andalusian School of Public Health in Granada, Spain, whose own elderly father lives in a nursing home that has banned visitors because of the COVID-19 pandemic.

And as many nursing homes have done, prisons and jails have banned visitors to reduce the risk of introducing COVID-19 to their facilities. The US Bureau of Prisons (BOP), which oversees 122 facilities housing 146 000 inmates and contracts with a dozen private prisons that house an additional 21 000 inmates, has suspended social as well as legal visits. All states and the District of Columbia have suspended social visits in their prisons, and 13 states and the District of Columbia have also suspended legal visits, according to the Marshall Project, a nonprofit news organization.

What Comes in Will Go out

One thing is clear, Lopez Acuña and other public health experts say: When it comes to the highly infectious virus that causes COVID-19, what happens in correctional facilities does not stay in correctional facilities, because staff members as well as incarcerated individuals come and go.

That is why “it’s very important to keep the virus from entering the prisons,” and, if it does, to keep it from exiting, said Lopez Acuña, former director of the WHO’s Health Action in Crises Recovery and Transition Programmes.

“If they are severe enough, you will have to send them to hospitals,” he said of incarcerated people with COVID-19. “If they are mild cases, you may have to have dedicated facilities for positives. This is not an outbreak of food poisoning. This is a really aggressive virus.”

“This pandemic is shedding a bright light on the extent of the connection between all members of society,” a group of Johns Hopkins University faculty wrote March 25 in a letter to Maryland Governor Larry Hogan. “Jails, prisons, and other detention facilities are not separate, but are fully integrated with our community.”

The letter, whose signatories included Joshua Sharfstein, MD, a vice dean at the Bloomberg School of Public Health and JAMA contributor, and School of Nursing Dean Patricia Davidson, PhD, Med, RN, urged Hogan to take such steps as ensuring incarcerated individuals have access to sufficient soap and hand sanitizer at no charge, stopping collection of fees or co-pays from them for medical care, and releasing those held for nonpayment of fees and fines or inability to post bail.

Release Some, Advocates Say

To say that the US corrections system is big and crowded would be an understatement.

Approximately 655 out of every 100 000 people living in the United States is incarcerated, or a total of 2 121 600, according to the World Prison Brief (WPB), a database compiled at the University of London. Both its incarceration rate and its incarcerated population are the highest in the world, according to the WPB, which indicated that the US system of prisons and jails was operating at 3.9% over capacity in 2014.

“In general, we are incarcerating more people than public safety really demands,” said Harvard internist Laura Hawks, MD, who studies how incarceration affects health and provides care for people who’ve recently been released. As the COVID-19 pandemic has unfolded, many in public health have recommended that corrections facilities exercise their option to release incarcerated individuals to home confinement.

“The most important thing is to get people who do not need to be there out,” Hawks said. “The flip side of that is you want to be careful about having people leave who are symptomatic or could be asymptomatic.”

Many incarcerated individuals have neared the end of their sentence for nonviolent crimes. Others, as the Johns Hopkins faculty noted in their letter to the Maryland governor, haven’t even been convicted yet but are being held because they couldn’t post bail.

Releasing some of them not only helps alleviate crowding in prisons and jails but also reduces their risk of contracting COVID-19, which could be a death sentence for some, Hawks noted. For example, she said, the rate of COVID-19 infection inside Rikers Island, New York City’s main jail complex, is many times higher than the rate in the surrounding community.

About 10 000 people incarcerated in federal prisons are older than 60 years, and about a third of all those incarcerated in federal facilities have an underlying condition that increases their risk of severe COVID-19, US Attorney General William Barr said at a briefing March 26.

The previous week, he said, he had asked the BOP to see if it was possible to increase the number of older individuals released to home confinement. While 40% of those older than 60 years were sentenced for violent crimes or sex offenses, many of the remainder who’ve served the bulk of their sentence no longer pose a threat, Barr said. Before being released to home confinement, people must spend 14 days in quarantine to make sure they won’t infect members of their household.

Barr acknowledged that remaining in prison might be safer for some who are eligible for home confinement, and that prisons will assess those circumstances on a case-by-case basis. As Hawks noted, homeless individuals have a higher risk of incarceration, so they might not have any place to go if they were released.

“We want to make sure that our institutions don’t become petri dishes,” he said. “But we have the protocols that are designed to stop that, and we are using all the tools we have to protect the inmates.”

As of April 2, 75 incarcerated individuals and 39 staff at its facilities had tested positive, according to the BOP. On March 28, just 2 days after Barr’s briefing, the BOP announced the first death of an incarcerated individual in one of its facilities.

Patrick Jones, who was 49 years old, had been in a low-security facility in Oakdale, Louisiana—where 7 incarcerated individuals and 3 staff had tested positive as of March 30—since April 2017. He was serving a 27-year sentence after being convicted in Texas for possession of cocaine with intent to distribute within 1000 feet of a junior college. Jones had chronic conditions that increased his risk of severe COVID-19, according to the BOP.

“The tragic death of Patrick Jones…is the first of what we anticipate will be many preventable deaths to COVID-19,” Kassandra Frederique of the Drug Policy Alliance, a nonprofit that advocates decriminalization of responsible drug use, said in a press release. “While we are encouraged by the actions taken by some state officials to begin releasing people, it is not enough, and it simply isn’t being done at the volume and speed necessary to outrun the virus.”

“If the only trick you’ve got in your quiver is reduce the size, then you’re neglecting a lot of other things that need to be done,” said Spaulding, who directs the Center for the Health of Incarcerated Persons (CHIP) at Emory’s Rollins School of Public Health, where she teaches a course in corrections health care epidemiology.

Every person entering a corrections facility should be screened by taking their temperature and asking them whether they’ve been in contact with an infected individual or have any symptoms, said Spaulding, who has posted PowerPoint presentations about dealing with COVID-19 in jails and prisons on the CHIP website. Staff as well as contractors working at prisons and jails should be sent home immediately if they’re sick, no questions asked, she said.

Spaulding previously served as medical director of the Rhode Island Department of Corrections, which oversees prisons and jails in that state, and as associate director of Georgia Correctional Healthcare, which provides health care to all individuals incarcerated by the Georgia Department of Corrections. She also worked 1 day a week in Atlanta’s Fulton County Jail and now provides care to low-income patients, including the homeless, at a clinic operated by Mercy Care in Atlanta.

Even since before the pandemic, every new detainee at the Fulton County Jail has undergone an assessment by jail medical staff, including a temperature check. By March 30, 14 jailed individuals, all men, had tested positive for COVID-19. The first man was hospitalized and has been released from custody, while the rest are being treated in the jail, where they’ve been isolated.

But the jail had not been able to follow the CDC recommendation to take the temperature of employees, vendors, lawyers, and others who entered the facility until Spaulding donated a noncontact infrared thermometer from Mercy Care after the first person in custody tested positive. (About a week later, she succeeded in obtaining a large bucket of hand sanitizer for the jail from Atlanta’s Old Fourth Distillery, which has switched from making vodka to making the more precious alcohol-based commodity.)

The problem is that the jail has 2 entrances but only the 1 infrared thermometer from Spaulding.

“We’re in dire straits,” Lt Col Adam Lee, assistant chief jailer, said March 27—when only 5 incarcerated individuals had tested positive—in an interview on a local National Public Radio station. “We’ve had to go online and try to see if we can order some of this stuff through Amazon or eBay or any of the other online shopping networks. We haven’t been successful.”

Unfortunately, it took a little while for the public to acknowledge and recognize the issues of COVID-19 in correctional facilities. Recently, there has been an increasing concern on this matter. It took a crisis like this for folks to become sensitive to those incarcerated. There are physicians, nurses, mid-level providers, correctional officers and others who for years have dealt with conditions of close confinement and limited mobility of an unfortunate population who are incarcerated. The American College of Correctional Physicians, the National Commission on Correctional Health Care, the American Correctional Association and others, have dedicated their lives to serving them. I'm certain many of you have never heard of these organizations. But for economic reasons resources are severely limited for jails & prisons. Politicians and the public are reluctant to address and use taxes for prisoner needs. The incarcerated have become "cast-aways". Now, all of a sudden the public is concerned and rightfully so. Politicians are still quite slow to enact legislation addressing the needs of offenders and those who care for them. Maybe this will be a wake-up call. These are our relatives, friends, neighbors and those we encounter daily (and not know it). I've been listening to webinars on the subject of coronavirus and rarely do the "experts" address this topic relating to correctional facilities. And when asked the responses are vague and non-committal. It's as if they never thought about. (I doubt if they have given it any serious thought.) I hope this and other emerging articles on this subject alert our medical profession and the politicians and the public that there is a segment of our society that cannot and should not be forgotten. Social distancing in a jail? Masks in prisons? Now that we are all "confined" with limited resources perhaps we can understand and have experienced what inmates experience daily! Thank you for alerting us on this matter.